Use of Quarantine to Prevent Transmission of Severe Acute Respiratory Syndrome—Taiwan, 2003

Use of Quarantine to Prevent Transmission of Severe Acute Respiratory
Syndrome—Taiwan, 2003

MMWR. 2003;52:680-683

1 table, 1 figure omitted

On July 5, 2003, Taiwan was removed from the World Health Organization
(WHO) list of severe acute respiratory syndrome (SARS)–affected countries.
As of July 9, a total of 671 probable cases of SARS had been reported in Taiwan.
On February 21, the first identified SARS patient in Taiwan returned from
travel to Guangdong Province, mainland China, by way of Hong Kong. Initial
efforts to control SARS appeared to be effective; these efforts included isolation
of suspect and probable SARS patients, use of personal protective equipment
(PPE) for health-care workers (HCWs) and visitors, and quarantine of contacts
of known SARS patients.1 However, beginning in mid-April, unrecognized
cases of SARS led to a large nosocomial cluster and subsequent SARS-associated
coronavirus transmission to other health-care facilities and community settings.2 In response to the growing epidemic, additional measures were taken
to limit nosocomial and community transmission of SARS, including more widespread
use of quarantine. By the end of the epidemic, 131,132 persons had been placed
in quarantine, including 50,319 close contacts of SARS patients and 80,813
travelers from WHO-designated SARS-affected areas. This report describes the
quarantine measures used in Taiwan and discusses the need for further evaluation
of quarantine and other control measures used to prevent SARS.

Beginning March 18, persons who had been in close contact with a SARS
patient were quarantined for 10-14 days (Level A quarantine); initially, quarantine
was for 14 days, but after June 10, the time was changed to 10 days in accordance
with the incubation period for SARS. Close contact was defined as the following
eight types of exposures: (1) HCWs who were not wearing PPE when evaluating
and/or treating a SARS patient; (2) family members who provided care for a
SARS patient; (3) persons who worked in the same office and whose cubicles
or work stations were located within 3 meters (10 feet) of a SARS patient's
work area; (4) friends of a SARS patient, as deemed appropriate by local health
authorities; (5) classmates or teachers of a SARS patient who attended a class
for ≥1 hour with the patient; (6) persons who sat in the same or adjacent
three rows from a SARS patient on an airplane flight; (7) passengers and drivers
of public transportation who traveled for ≥1 hour in the same bus or train
cabin with a SARS patient; and (8) persons who had contact with a person under
quarantine who received care in a medical facility in which a cluster of SARS
occurred. Hospital staff and patients who had contact with a SARS patient
were quarantined, usually in a health-care facility. All others were quarantined
at home. Homeless persons, who often use hospital toilet facilities, were
asked to go voluntarily to government quarantine centers under Level A quarantine.

During April 28–July 4, travelers arriving on airplane flights
from WHO-designated SARS-affected areas were quarantined for 10 days (Level
B quarantine). Arriving passengers could choose quarantine in an airport transit
hotel, at home, or at a quarantine site designated and paid for by their employer.
If these options were not available, the traveler was quarantined at a government
quarantine center located at military bases. On June 9, quarantine regulations
were eased for staff of Taiwanese companies based in mainland China who were
returning to Taiwan for business. Travelers in this category were allowed
to conduct business if they wore surgical masks. When not conducting business,
they were to follow the rules of quarantine.

Persons under quarantine were required to stay where they were quarantined;
take their temperature two to three times a day; seek medical attention promptly
if they had fever (≥100.4°F [≥38°C]), cough, shortness of breath,
or other respiratory symptoms; cover their nose and mouth with tissue paper
when coughing or sneezing; and wear surgical masks when around other persons
and outside the quarantine site. They were not allowed to use public transportation,
visit hospitalized patients, or visit crowded public places. Persons under
Level A quarantine could leave the quarantine site only for activities deemed
necessary by local health authorities; meals were delivered. Persons under
Level B quarantine were allowed to leave the quarantine site to seek medical
attention, exercise in an open area, purchase meals, dispose of garbage, and
perform other activities deemed necessary by local health authorities. All
outdoor trips were recorded to facilitate possible future investigations.
Failure to comply with quarantine regulations, submitting incomplete SARS
survey forms, or providing inaccurate contact information was punishable by
fines of U.S. $1,765–$8,824 and incarceration of ≤2 years.

The direct management and supervision of persons under quarantine was
conducted by local HCWs or civil servants. This activity included ensuring
the initial registration of all persons requiring quarantine; recording each
person's whereabouts, with information obtained either by daily visits or
telephone calls; overseeing the person's daily temperature recordings; evaluating
patients who reported a fever; and directing persons with possible SARS to
appropriate medical attention. Local health officials reported daily on the
status of quarantined persons to the Taiwan Department of Health through a
web-based database.

In addition to these measures, video monitoring was conducted for some
persons who were contacts of a SARS patient and quarantined at home. Although
the intervention was conceived initially for quarantine violators who were
residents of the high-population density areas of Taipei and Kaohsiung, the
low number of quarantine violators allowed broader use of this intervention.
By mid-May, video monitoring was used for almost all persons living in these
cities and under quarantine at home.

At government quarantine facilities, persons were placed in individual
rooms (not negative-pressure); meals were delivered. Police guarded the rooms
to ensure compliance with quarantine.

Several social supports were developed to ease the burden of quarantine
on persons and their families. Service providers telephoned quarantined persons
to provide psychologic support. Care was provided for the family members of
quarantined persons, including day care and care for ill persons. Persons
who completed quarantine received the equivalent of U.S. $147. Quarantined
persons could request other social services from local health or civil affairs
departments.

Of the 131,132 persons who were quarantined during the SARS epidemic
in Taiwan, 286 (0.2%) were fined for violation of quarantine. Of the 50,319
persons placed under Level A quarantine, 4,063 (8.0%) were placed on video
monitoring at home. A total of 112 (0.22%) persons had suspect or probable
SARS diagnosed while under Level A quarantine. Of the 80,813 persons placed
under Level B quarantine, 21 (0.03%) had suspect or probable SARS diagnosed.

The highest percentage of persons who had suspect or probable SARS diagnosed
subsequently were among HCWs exposed to a SARS patient (0.34%), family members
of a SARS patient (0.33%), and persons on the same airplane flight who sat
within three rows of a SARS patient (0.36%). Travelers arriving from SARS-affected
areas had the lowest percentage for subsequent SARS diagnosis (0.03%).

Quarantine, the separation and/or restriction of movement of persons
who are not ill but are believed to have been exposed to infection to prevent
transmission of diseases, was developed in the 14th century but has been implemented
rarely on a large scale during the past century.3,4 The SARS pandemic
has demonstrated that governments and public health officials might use quarantine
as a public health tool to prevent infectious diseases, particularly when
other preventive interventions (e.g., vaccines and antibiotics) are unavailable.
In Taiwan, only a small percentage of persons quarantined had suspect or probable
SARS diagnosed subsequently, and an even smaller percentage of persons quarantined
had a laboratory-confirmed case of SARS. However, because one infected person
could expose others and generate successive waves of infection, the use of
quarantine might have prevented additional cases. This possibility should
be examined through future mathematical modeling studies. Taiwan was one of
several countries that implemented quarantine measures during the global SARS
outbreak, and more study is needed to determine whether the logistics and
costs of quarantine warrant its use. Such studies should examine both the
direct (e.g., stipends, resources, personnel time, and lost work days) and
indirect (e.g., social stigma, curtailment of civil liberties [e.g., restrictions
on freedom of movement], declining personal and community mental health, and
delay in reporting symptoms) costs of quarantine.

Numerous SARS control measures were undertaken simultaneously, making
it difficult to determine the independent contribution of any one measure.
These other control measures included designating dedicated SARS hospitals
throughout the island; constructing additional negative-pressure rooms; instituting
fever-screening clinics for all health-care facilities; performing fever screening
on all persons entering public buildings and restaurants; and requiring masks
for all persons working in restaurants, entering hospitals, and using public
transportation systems. Evaluation of the contribution of all control measures,
including quarantine, should be performed to determine the appropriate role
of each intervention in response to future outbreaks.